Advanced Trainee in Emergency Medicine, Rob Mitchell, shares his insightful journey in global health and recent experiences in Papua New Guinea working in clinical education. Read on for Rob’s invaluable tips as well as current opportunities for those interested in kick starting their global health careers.
GHG: Tell us about yourself.
I grew up in Melbourne’s outer West, and was one of only two students in my year at Monash University to come from a suburb on the ‘other’ side of the West Gate Bridge. I’m now an advanced trainee in emergency medicine (EM) and am currently working as a registrar at the Royal Brisbane and Women’s Hospital.
Most of my training has been in regional hospitals, initially in Geelong and then Townsville in North Queensland. I was originally attracted to working in Queensland when I undertook a John Flynn Scholarship Scheme placement in the Torres Strait. Spending a short amount of time on Thursday, Murray and Boigu Islands was a wonderful learning experience, particularly from a cultural and historical perspective.
GHG: Why did you choose your career?
There are several reasons why I chose to specialise in Emergency Medicine, but a major factor is that there are no barriers to care (at least in the case of public hospitals.) All patients are welcome at any time, regardless of their age, their condition or their financial status. You could make the same argument for general practice, but EM appeals to my short attention span! Practically, it is also relatively straightforward to combine a career in EM with other interests (in my case, global health, workforce policy and educational activities).
A day in the emergency department (ED) is incredibly humbling. You meet fascinating people from all walks of life, with amazing stories to tell. It’s also a reminder of how tough some people do it. I’ve become involved in global health (GH) activities because my life circumstances allow it; not everyone has that luxury.
GHG: Can you tell us about a seminal experience in your career?
My interest in global emergency care – an emerging field of GH – was cemented following a final-year elective rotation to an ED in Madang, Papua New Guinea (PNG). I was thoroughly impressed by the resilience of patients and staff, and their capacity to provide quality healthcare in a resource-limited setting. I’ve since had some useful GH training experiences in Timor Leste and Tanzania, and have undertaken a Master of Public Health & Tropical Medicine (MPH&TM) and a Postgraduate Certificate in Disaster & Refugee Health.
As I progress through my training, I am increasingly interested in the role of emergency care systems in improving health outcomes in low- and middle-income countries. Access to acute care is a high priority for patients, and is an important component of achieving universal health coverage. There is emerging evidence about the positive impact of emergency care systems on efficiency, morbidity and mortality in resource-limited settings, but there are many unanswered questions.
I’m also interested in the concept of GH training, and how early career health professionals can develop the skills, knowledge and attributes required to safely and effectively contribute to GH. I’ve been involved with a number of projects to this end, including the MJA Guide to Working Abroad and a Churchill Fellowship looking at GH fellowship models in North America.
There are risks involved with trainees engaging in GH experiences, but observing ethical guidelines can minimise the risk of harm to host communities. The Australian Volunteers International (AVI) placement at Divine Word University (DWU) in PNG appealed to me because it is underpinned by long-term organisational relationships and has a strong focus on capacity development.
GHG: Tell us about your recent work in clinical education in PNG?
In 2014 I undertook an Australian Volunteers for International Development (AVID) assignment in Madang, PNG – the same town I visited as a humble medical student in 2008. I volunteered as a Visiting Clinical Lecturer (VCL) at DWU, and was able to have the term counted towards my advanced training in EM.
My primary role was to teach and supervise health extension officer (HEO) students undertaking their EM block. About half of my time was spent working clinically as an ED registrar at Modilon Hospital, the provincial referral facility. My partner Bec is an obstetrics and gynaecology trainee, and she undertook a similar role focussed on maternal health.
HEOs play a major role in the PNG health sector. They are middle grade health practitioners, analogous to medical assistants or clinical officers in other countries, and mainly work in rural and regional settings. PNG has 0.1 doctors per 1000 people (Australia has 3.9) so the country is heavily reliant on paramedical staff to deliver primary and secondary care.
HEO students undertake a four-year Bachelor of Rural Health through DWU. It’s essentially a condensed medical degree, with some additional public health components. There are very few academic staff in the Health Sciences Faculty, so the university has partnered with a number of international organisations to supply visiting tutors and lecturers.
GHG: What where your daily activities and responsibilities?
My major academic task was to help co-ordinate an EM teaching block. A local HEO tutor and I delivered lectures across a range of topics, from chest pain to snakebite to soft tissue infections. I also supervised students undertaking clinical rotations in the ED, and participated in assessment activities.
When I was working clinically, I functioned as a registrar alongside the other trainees working in the ED. We were collectively supervised by a local emergency physician, Dr Taita Kila, who was a wonderful mentor and teacher.
Patients present to Modilon Hospital ED with conditions reflecting the burden of disease in PNG – major trauma, severe malaria, advanced tuberculosis and snake envenomation, among many others. They often travel for days – by banana boat, public motor vehicle (minibus) or on foot – to access care. Some are so sick by the time that they arrive that it is difficult to turn their illness around, especially without access to advanced medical interventions. I witnessed some very sad outcomes during my time.
Apart from providing clinical care, I also had the opportunity to teach (including basic life support for the security guards, trauma ultrasound for the registrars and first aid for several community groups), introduce a new ED observation and management chart and help manage a major measles outbreak. These were certainly novel experiences for an Australian EM trainee!
GHG: What were some of the challenges you faced?
Some of the challenges were practical – such as language and security – but others were cultural (understanding social norms and the complexities of Melanesian life). There were technical hurdles – like learning PNG treatment protocols for tropical infections – but I also found myself confronting difficult ethical questions – for instance, determining appropriate ceilings of care in a resource-limited environment. Those who have worked in cross-cultural environments will be familiar with these types of challenges.
Working at DWU and Modilon Hospital was a wonderful experience. Our colleagues were extremely hospitable, and made us feel incredibly welcome. They were very understanding of our poor language skills (which improved a lot in the course of the placement) and took time to teach us about medicine and culture in PNG. We also tried to make the most of the stunning environment, and would spend our weekends kayaking and snorkelling in and around the nearby islands.
I feel guilty because I think I got more out of the assignment than I was able to impart. I hope, however, that my meagre contribution has had a small impact on the delivery of emergency care in PNG. My sense is that the VCL role is mutually beneficial – visiting trainees develop skills in cultural humility and tropical medicine, while the HEO students and ED staff benefit from teaching and training delivered by a visiting clinician with a different set of skills and experiences.
GHG: What are your tips for people interested in working in global health?
For doctors interested in GH, I would highly recommend undertaking a term abroad as an advanced trainee. Australian registrars have typically enjoyed many years of high quality and education and training, and have a lot to offer in developing settings.
Colleges are slowly responding to trainee demand for GH experiences. The Australasian College for Emergency Medicine (ACEM) has led the way in many respects, but opportunities also exist within other training programs. A good example is The Alfred-MSF TB registrar position for an advanced trainee in infectious diseases.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has also come on board as a partner of the VCL program in Madang, and there is potential for O&G trainees to have this term accredited towards their training.
Before heading abroad, it’s really important to think about what you want to achieve, and how you might be able to contribute. The MJA Guide to Working Abroad includes advice on these matters. The risk of harm to host communities is real, so it’s important that placements have a firm ethical foundation and defined development objectives. An advantage of undertaking a rotation as part of a training program is that is mandates appropriate supervision.
I would highly recommend a deployment with AVI through the AVID program. AVI take care of logistics (including visas, travel and medical registration) and provide a volunteer stipend (which is more than enough to live off in PNG). They also linked us with a security provider, who provided advice about safety and security and assisted with after-hours transport.
The skills and knowledge acquired through the MPH&TM proved extremely useful. There is still a huge amount that I don’t know about tropical medicine and communicable disease control, but it was helpful to have a theoretical basis prior to the deployment. I would encourage all trainees interested in GH to undertake some additional study in public health and related areas.
I also think it’s critical to identify GH mentors. There are several individuals who have provided me with valuable advice along the way. During my time in PNG, I naturally found myself in challenging situations – for both clinical and cultural reasons – and it was useful to discuss and decompress with trusted senior colleagues.
As health professionals in a high-income country, we are incredibly fortunate to have the opportunity to work in cross-cultural and international environments. I learned a great deal from my colleagues and patients in PNG, and I feel privileged to have had the chance to spend a short period of time in Madang. I remain in touch with the university and hope to return before too long.
There is no defined GH career path in Australia, but individuals can bundle together learning opportunities to develop their knowledge and skills. Undertaking an AVID assignment is a great option for early career health professionals to gain valuable experience but also contribute meaningfully to GH development.
Tenk yu tru!
Featured photos taken at Modilon Hospital ED by Darren James (a Melbourne based photographer).